Mindset Reps @ Official Fitness Registration Form

Athlete Name

First NameMiddle NameLast Name

Guardian

First NameLast Name

Grade

Athlete Birth Date

MonthDayYear

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Athlete E-mail

example@example.com

Mobile Number

Format: (000) 000-0000.

Guardian Phone Number

Format: (000) 000-0000.

Guardian Email (Or athlete if over 18)

example@example.com

Courses

T-shirt size (unisex)

Shoe Size (specify men's or women's sizing)

Tell us more! What are you hoping to gain from this course?

How did you hear about us?

Are you an agency making a referral? If so, which agency?

How will you be paying for this course?

Mindset Reps (and FYR) Exercise Release Waiver Participating Gyms Including: Old Town Athletic Club, CrossFit 970 and OTAC CrossFit, KODA Ironview, Official Fitness and offsite activities. Mindset Reps and FYR Mindset Reps, involves weightlifting, sprinting and gymnastics all of which subject participants to potential injury that is inherent in the nature of the activities. By agreeing to workout at Mindset Reps you agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death or loss of personal property. This waiver and release of liability includes, without limitation, all injuries which may occur as a result of, (a) your use of all amenities and equipment in the facility and your participation in any activity, class, program, personal training or instruction, (b) the sudden and unforeseen malfunctioning of any equipment (c), the actions of fellow participants in the club while taking part in any activity, class, program, personal training or instruction (d) our instruction, training, supervision, or dietary recommendations, and (e) your slipping and/or falling while in the club, or on the club premises, including adjacent sidewalks and parking areas.Because exercise can be strenuous and subject participants to risk of serious injury, Mindset Reps urges you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You (each member, guest, and all participating family members) agree that if you engage in any physical exercise or activity, or use any Mindset Reps amenity on the premises or off-premises including any sponsored club event, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements, weight reduction and or body building enhancement products are entirely your responsibility and you should consult a physician prior to undergoing any changes.You expressly agree to release and discharge Mindset Reps, and all affiliates, employees, agents, representatives, successors, or assigns, from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against Mindset Reps for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Mindset Reps, its agents, and employees.If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally. You acknowledge that you have carefully read this "waiver and release" and fully understand that it is a release of liability.Signature

Youth Resilience Mindset Reps is piloting a program to measure the impact our programs have on youth participants' physical and mental health. This will entail an anonymous pre and post written assessment and fitness benchmark which will be reviewed by researchers at the end of every 12 week period. No names will be released. Please sign the box below if you (your child) consents to participating in this program.

FYR Mindset Reps Media Release Form

I consent to the unrestricted use, by Forging Youth Resilience; Mindset Reps, LLC) (and those acting with its permission and authority), of any and all media taken, in whole or in part, unlimited use, for all purposes in any form or medium, including, without limitation, its use through or on any electronic media, including the Internet.
I waive any right to inspect or approve the finished product or products or the advertising copy or printed matter that may be used with the finished media.
Further, I relinquish all rights, titles and interest I may have in the finished media, negative(s) and reproduction to any responsible business firm or publication. It is understood that Forging Youth Resilience Mindset Reps retains copyright of media at all times under the express understanding and agreement that Forging Youth Resilience shall have exclusive reproduction rights to the media.
I hereby release Forging Youth Resilience from any and all claims in connection with the media, including any and all claims of libel.

Please select below for media consent selection.

Please select the following payment option:

Mindset Reps Full Discounted Tuition

$397.00 Quantity

Mindset Reps Partial Scholarship

$300.00 Quantity

Mindset Reps Partial Scholarship

$150.00 Quantity

Mindset Reps Full Scholarship

Free Quantity

Full Tuition

$720.00

Total

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Teen Mental and Physical Fitness Official Fitness, Windsor Starting June 19- August 25! Tuesdays 6:00-7:30PM

Please fill out all forms below.

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